2020 Essay Contest - Honorable Mention: High Productivity Demands Are Negatively Impacting Patient Quality of Care by Jeffrey Sass
As a first-year physical therapy student, one message our professors repeat time and time again is the importance of using evidence-based practice to guide our decision making to create the best outcomes for our future patients. Their goal of ingraining this concept is due to the abundance of treatment options that are available. Becoming an excellent clinician is not just about being able to perform a myriad of techniques of the profession, but to also be able to select the optimal interventions to give the patients the best opportunity to recover. Although physical therapists are trained to apply evidence-based practice to their treatment plans for their patients, the burgeoning demand for productivity goals could diminish this approach and unintentionally lead to unethical decision making. I believe the rise in productivity goals is the most unresolved issue in rehabilitation practice today.
Productivity is a percentage of how long a physical therapist is spending with their patients doing treatments that are considered billable by the insurance companies. Clinicians that work in a productivity-driven environment are obligated to spend the majority of their day doing billable treatments with their patients. Without knowing the details of what therapists have to do in order to treat their patients, this policy would sound like a positive requisite. How could a “patient-focused” policy be anything less than advantageous? A cross-sectional survey study titled, “Are Productivity Goals in Rehabilitation Practice Associated with Unethical Behaviors?” revealed that clinicians expressed that elevation in productivity goals in rehabilitation practices increases the rate of unethical behavior. 1 In short, high demands of productivity are preventing clinicians from getting to use the evidence-based practice they were trained for years to do. This leads to the question, how do productivity goals impact patient care and lead to unethical behavior?
Facilities that are driven by productivity standards produce an atmosphere of stress and tension on the physical therapists. This is due to the significant time constraints where therapists are not afforded adequate time to thoroughly prepare and plan for their patients’ goals and session requirements. Most clinicians will spend time chart reviewing new patients that are on their schedule, confer with other healthcare professionals about the status of their patients, and spend time optimizing treatment options for their patients for the day. As the demands of productivity begin to take over the goals of clinicians, their decision-making process starts to become misdirected. To better understand the productivity demands on physical therapists, a clinician working in a skilled nursing facility was interviewed. “It is like having blinders on,” described the physical therapist. They lamented that high productivity goals shift the focus from doing what is best for each individual patient, to defining the most efficient way to treat the entire group of patients within the allotted time. They reported that unanticipated events occur regularly, preventing patients from participating in therapy at the precise time scheduled. This creates multiple points of stress as it is necessary to quickly find another patient to fill the vacant spot before their productivity drops, and the therapist faces repercussions from the facility. Ultimately, falling below the facility's productivity standards is the trepidation that drives these clinicians' treatment plans, rather than optimizing treatment sessions with methodical goals.
The demands of high productivity can force clinicians to minimize other significant components related to treating their patients. Interprofessional communication is one of the most critical factors for creating the best outcome for patients. A patient’s status could improve or decline very rapidly, which forces healthcare professionals to constantly adapt their treatment strategies. Persistent and lucid communication is essential in these circumstances to adjust treatment options for the patients to ultimately get them healthier. As therapists start to feel pressured to maintain high productivity, treatment skills such as interprofessional communication tend to diminish, leaving opportunities for unintentional mistakes. This combination of factors is potentially detrimental to a patient’s quality of life.
Finally, one of the most essential components of becoming a physical therapist is proper documentation. As a student, it is made abundantly clear that meticulous and thorough documentation is a requirement. Accurate and quality documentation is a way for physical therapists to communicate with each other about their treatment sessions. A therapist should be able to review a colleague's notes for a specific patient and replicate that treatment. Facilities that have productivity requirements generally allot a small amount of time for the clinicians to document. Some clinics will emphasize point of service documentation, which means that the clinician needs to document at the same time they are treating their patient.
Imagine an environment where the therapist already feels behind because a patient is not ready, and their productivity is steadily decreasing. Now the anxious therapist has to multitask documenting while treating their patients. It is evident how unethical decision making occurs. Physical therapists are already clocking-out to document to prevent negatively affecting their productivity. Those same clinicians will document through their lunch, a sandwich in one hand and typing with the other. It appears that these clinicians are already between a rock and a hard place. Since other tasks like answering the office phone, cleaning up after a treatment session, and calling the patient's primary care provider to get some vital information are not considered billable time, these essential tasks may negatively affect their productivity. The decline in productivity and fear of getting reprimanded could potentially incentivize a clinician to create a fraudulent billing scenario by adding billable minutes to a previous treatment session. Also, productivity could force a physical therapist to use an intervention that might not be appropriate or the best option for their patients. One such example of this unethical decision making would be a therapist deciding to put a patient with walking goals on a therapy bike to allow the clinician to do a concurrent treatment or document at the same time to catch up on productivity. Thus, evidence-based practice decision making begins to dissipate by the pressures of productivity goals.
I used to work for a CEO who would say, “If you present a problem without a solution, then you are just whining.” This begs the question, what is the solution to the rise in productivity goals? Perhaps, the most straightforward solution to this problem is to put a lower cap on how high the productivity requirements should be at a facility. Most stakeholders would agree that the focus of a treatment session should be dictated by the goals of the patient and the evidence-based practice the physical therapists apply, and not constructed around productivity obligations. “Sorry Mrs. Jones, we did not get your mother out of her wheelchair in therapy today because my productivity with my other patients has been too poor. I just had your mom do some wheelchair marches instead of going for a walk.” Although Mrs. Jones is a fictitious family member, it is doubtful that explaining productivity standards in this way would be advantageous for the clinician.
One could argue that productivity goals are what keep facilities afloat and profitable. How could someone debate that a clinician that is 70% productive can make as much money for the facility as someone that is at 90% productivity? This mindset does not factor in what else a physical therapist could do to help make their facility profitable. Reducing productivity standards frees up physical therapists to find other means to benefit their facility. There is a big push for therapists to do concurrent and group treatments when deemed appropriate, but the problem is that these tasks take a lot of planning to be beneficial to the patients. Decreasing productivity restraints could allow therapists more time to plan these group treatments and still apply evidence-based thinking to the sessions. Therapists could also screen for potential evaluations, which emphasizes primary prevention care. Primary prevention focuses on facilitating actions to prevent a disease or disorder from occurring, such as catching a potential fall risk before the patient has fallen and sustained a fracture. “Mrs. Jones, I know your mother is not on caseload for physical therapy, but I saw her walking the other day and saw that she is having some balance issues that could potentially lead to a fall. We believe your mother would be a good candidate for physical therapy to address potential fall risk.” One could argue a family member would be far more receptive to this scenario than the previous discussed one.
Finally, I wanted to finish this disquisition on what I started it with, evidence-based practice. Through years of schooling, clinical experience, and continuing education requirements, physical therapists are constantly being educated on the best techniques to treat their patients. By lowering productivity requirements, physical therapists will be able to apply more of that harnessed knowledge they spent years acquiring and honing. This will cause an improvement in patient compliance and outcome measures. My professors spend copious amounts of time training us on how each patient is unique. “It-depends” is the widely accepted ambiguous answer given to specific questions on how to treat patients. Not only does the therapist need to be able to evaluate the functional limitations and restrictions of the patient, but also the psychosocial factors. Cookie-cutter treatments will fail to discover these idiosyncrasies, thus limiting the potential outcome of the patients. Productivity driven goals will continue to strong-arm physical therapists to fall into this one size fits all trap with how patients are viewed and treated.
Physical therapists connect indelibly to their patients in a way that not many other professions can. It is those clinicians that will push their patients to move. It is those clinicians that will comfort and motivate their patients. Ultimately, it is those clinicians that will add quality of life back to their patients and not the facility’s high productivity goals.
- Richardson RW. Ethical issues in physical therapy. Curr Rev Musculoskelet Med. 2015; 8(2):118–121. doi:10.1007/s12178-015-9266-y